The problem of DTOC has basically been addressed, but the problem of demand most certainly has not.
The Care Quality Commission (CQC) recently published a report investigating how local health and social care systems in Sheffield work together. The report praised the commitment to working together to improve outcomes for people, but was clear that this ambition ‘had not yet been clearly articulated as a strategy that is understood by all parts of the system’. The report found that although Sheffield’s health and care systems can react decisively to a crisis, short term pressures are distracting from the development of a long term, sustainable strategy.
This led me to consider commissioning, that often-ignored and misunderstood element of both systems. Within commissioning functions, health and social care services are designed, developed and delivered, and good commissioning can challenge and change the way things are done. Implementation is critical and needs to be forward-facing, long term and transformational, involving a range of partners focused on person-centred services and on outcomes.
Unfortunately, this is often not happening as effectively as it should – but why? Is it that the different values and cultures in the health and social care sectors impact on successful joint commissioning practice?
Values influence how people, groups and organisations think, behave and act. They are beliefs that inform what good looks like and how individuals define failure. Decisions around services in health and social care are based on a perception of what is best for society. These values are crucial when considering how a system commissions (and how it doesn’t), both as individual organisations and as a joined up system.
So how can we use commissioning to bring greater alignment across the health and social care systems, and use it as a lever to deliver better outcomes for less?
From my perspective, this takes more than a strategy or a set of principles laid out in a Sustainability and Transformation Partnership. There can be real differences of opinion in areas such as understanding the role of prevention, self-care, personalisation and strengths-based conversations with patients.
To overcome these differences, the system needs real leadership that takes practical steps to promote shared values and understanding. There are four key areas where a strong and strategic commissioning system can both create alignment, and respond to the national pressure around Delayed Transfers of Care (DTOC) and emergency admissions:
- ADMISSIONS AVOIDANCE: Intermediate care rapid response. Emergency admissions continue to increase across the country, and too little attention has been given to joint step up services in the community that can respond quickly, and have established links into those high cost patients that are most at risk of hospital admissions.
- OPTIMISING FLOW: the increasing emphasis on DTOC, and the evidence demonstrating the negative impact of hospital stays on a person’s independence, means that solutions between acute and community providers must be optimised to create single referral processes, multidisciplinary team (MDT) triage and established clear pathways out of hospital.
- THE RIGHT SUPPLY: Intermediate care supported discharge: CCGs and local authorities need to work together (utilising their BCF and iBCF funds) to create the right suite of intermediate care services to support discharge and prevent an overreliance on long term care packages. This supports a Discharge to Assess (D2A) model where assessments can take place outside of an acute setting. It is also a crucial area to build trust across the health and social care systems, by improving outcomes through joint commissioning.
- COMMUNITY PREVENTION: Working with community organisations and care planning: Targeted risk stratification and care planning for the most vulnerable and highest users of acute services can allow both health and care to better manage demand. Community groups are increasingly commissioned by both the health and social care sectors to provide prevention, early intervention and low-level support services. Aligning the outcomes of these services is a key area for preventing, delaying and reducing need in the community.
For a system change to be put in place, greater focus on deciding how shared values are created, commissioned and then embedded is needed. IMPOWER has developed a quality assurance framework to help review existing systems at the health and care interface, and has worked with clients to develop intermediate care models that can reduce DTOC and maximise people’s independence. If you would like to talk to us about the commissioning solutions that we can offer, please get in touch.